the liver methods of examination 1. us 2. ct 3. mri 4. nuclear medicine
TRANSCRIPT
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THE LIVER
Methods of examination
1. US2. CT3. MRI4. Nuclear medicine
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CIRRHOSIS
Pathologically cirrhosis consists of varying amounts of hepatic necrosis, fibrosis, fatty infiltration and nodular regenerationTypes:1.Chronic sclerosing cirrhosis – minimal regenerative activity of hepatocytes, little nodule formation, liver is hard and small.
2. Nodular cirrhosis – regenerative activity with presence of many small nodules; initially the liver may be enlarged.
Causes – alcohol, hepatitis B, hemochromatosis
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Radiographic featuresLiver- Small liver, increased echogenicity, heterogeneous- Nodular surface- Regenerating nodules – hypoechoic- Unequal distribution of cirrhosis in different segments – left lobe appears larger than right lobe; lateral segment of left lobe enlarges, medial segment shrinks; ratio of the width of the caudate lobe to the right hepatic lobe is 0,6Portal hypertension- Collaterals – left gastric, paraesophageal, mesenteric, splenorenal- Splenomegaly- AscitesComplications – hepatocellular carcinoma, esophageal varices with bleeding
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FATTY LIVERCauses – obesity, alcohol, hyperalimentation, debilitation, chemotherapy, steroidsRadiographic findingsUS – fat increases liver echogenicity, renal cortex appears more hypointense relative to liver than normal, intrahepatic vessel borders become indistinct or cannot be visualized, nonvisualization of diaphragmCT – fatty areas are hypodense, hepatic and portal veins appear dense because of decreased parenchymal density
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PYOGENIC ABSCESSPathogens – Escherichia Coli, aerobic streptococci, anaerobesCauses – ascending cholangitis, trauma, surgery, portal phlebitis.Radiographic features- CT – hypodense with peripheral enhancement, no fill-in.- Double target sign – wall enhancement with surrounding
hypodense zone.- 30% contain gas.- any abscess can be drained percutaneously, particularly: deep
abscesses, no response to treatment, nonsurgical candidates.
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HYDATID DISEASEHumans are intermediate hosts of the dog tapeworm (taenia echinococcus). Two forms: E.granulosus – more common, few large cystsE.multilocularis – less common, more invasiveRadiographic featuresE.granulosus- well-delineated cysts- size of cysts usually very large- daughter cysts within larger cysts ( multiseptated cysts) are
pathognomonic- rimlike cyst calcification- double rim sign: pericyst, endocyst- enhancement of cyst wall
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E.multilocularis
- poorly marginated, multiple, hypodense liver lesions.- lesions are infiltrative (chronic granulomatous reaction with
necrosis, cavitation).-calcifications are punctate and dystrophic, not rimlike.
Complications- rupture into peritoneal, pleural, pericardial cavity- obstructive jaundice due to external compression or intrinsic
obstruction of biliary tree
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HEMANGIOMA- Frequency – 4-7% of population, 80% in females.Hemangiomas
may enlarge particularly during pregnancy or estrogen administration.
US- hyperechoic lesions 80%.- hypoechoic lesions especially in fatty liver.- giant hemangiomas are heterogeneous.- anechoic peripheral vessels may be demonstrated by color
Doppler .CT- hypodense, well-circumscribed lesion on precontrast scan
globular or nodular intense enhancement. MRI- hyperintense on heavily T2W sequences.- imaging modality of choice.Nuclear imaging (SPECT)- decreased activity on early dynamic images.- increased activity on delayed blood pool images.
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HEPATOCELLULAR CARCINOMA (HCC)Risk factors – cirrhosis, chronic hepatitis B, hepatotoxins, metabolic disease in paediatric patients Radiographic featuresGeneral- three forms – solitary, multiple, diffuse- portal and hepatic vein invasion is common- metastases – lung, adrenal, lymph nodes, bone
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CT- hypodense mass lesion- early arterial enhancement-Pseudocapsule
US- most small HCC are hypoechoic- larger HCC are heterogeneous-high-velocity Doppler pattern
Angiography - hypervascular- AV shunting is typical- Dilated arterial supply
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METASTASES30% of patients who die of malignancy have liver metastases.Colorectal carcinoma, stomach, pancreas, breast, lungSensitivity for lesion detection: CTAP – high-dose delayed CT – CECT,MRI – US- Echogenic MTS – GI malignancy, HCC, vascular- Hypoechoic MTS – lymphoma, bull’s eye pattern (hypoechoic halo around lesion)- Calcified metastases – all mucinous metastases – colon, thyroid, ovary, kidney, stomach- Cystic metastases – necrotic leyomiosarcoma
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PORTAL HYPERTENSIONCriteria – hepatic wedge pressure 10 mm Hg. Causes:PresinusoidalExtrahepatic (obstruction of portal vein) – thrombosis, compressionIntrahepatic (obstruction of portal venules) – hepatic fibrosis, infection SinusoidalCirrhosis ,sclerosing cholangitisPostsinusoidalBudd-Chiari syndrome, congestive heart failure Radiographic features- Portal vein diameter 13 mm- Collateral vessels – gastroesophageal varices via coronary vein, azygos; SMV collateral – mesenteric varices; splenorenal varices; IMV collateral – hemorrhoids- Splenomegaly- Ascites
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THE BILIARY SYSTEMMethods of examination
1. Abdominal plain film – gas or calcium in the biliary tract2. US3. CT4. MRI + MRCP5. ERCP6. PTC7. Scintigraphy
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ACUTE CHOLECYSTITISCauses - gallstone 95%US - Luminal distension 4cm- Wall thickening 5 mm (edema, congestion)- Gallstones- Pericholecystic fluidComplications - Gangrenous cholecystitis: rupture of GB- Emphysematous cholecystitis- Empyema
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CHRONIC CHOLECYSTITIS
- GB wall thickening (fibrosis, chronic inflammation)- Gallstones- Failure of GB to contract
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CHOLELITIASISTypes:Cholesterol stones are caused by precipitation of
supersaturated bile- Pigment stones – precipitate of calcium bilirubinate- Mixed stonesPredisposing factors:- Obesity- Hemolytic anemia- Abnormal enterohepatic circulation of bile salts- Diabetes- Cirrhosis- HyperparathyroidismUS – method of choice – hyperreflective image with
prominent posterior shadow; mobility of stones (exception – stones impacted in neck or stones adherent to wall)
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CHOLANGIOCARCINOMAAdenocarcinoma of the biliary tree.Clinical – jaundice, pruritus, weight loss.Treatment – pancreaticoduodenectomy or palliative procedures (
stent placement, biliary bypass)Location – hilar (originates from epithelium of main hepatic ducts or
junction –Klatskin tumor) + peripheral – originates from epithelium of intralobular ducts
Radiographic features- Dilated intrahepatic ducts- Hilar lesions – central obstruction + lesions are usually infiltrative
so that a mass is not usually apparent + encasement of portal veins causes irregular enhancement by CT
- Peripheral lesions – may present as a focal mass or be diffusely infiltrative + retain contrast materials on delayed scans + occasionally invade veins
- ERCP very useful
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THE PANCREASMethods of examination
1. CT2. US3. MRI + MRCP4. Arteriography
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PANCREATITISClassification - Mild acute pancreatitis (interstitial edema)- Severe acute pancreatitis (necrosis, fluid collections)- Chronic pancreatitis
Causes- Alcohol- Cholelitiasis- Abdominal trauma- Hyperlipidemia, hypercalcemia- Drugs – azathioprine, sulfonamides- Peptic ulcer- Pregnancy
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Imaging – CT stagingGrade A – normal pancreatic appearanceGrade B – focal or diffuse enlargement of pancreasGrade C – pancreatic abnormalities and peripancreatic
inflammationGrade D – 1 peripancreatic fluid collectionGrade E – 2 peripancreatic fluid collections and/or gasComplications- Necrosis - Acute fluid collections – enzyme-rich pancreatic fluid, no
fibrous capsule- Pseudocyst – encapsulated collection of pancreatic fluid- Abscess- Hemorrhage
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CHRONIC PANCREATITISProgressive, irreversible destruction of pancreatic parenchyma by repeated episodes of mild or subclinical pancreatitis.
Radiographic featuresCommonly small, atrophic pancreasFatty replacement, fibrosis, calcificationsIrregular dilatation of pancreatic duct
ComplicationsPseudocystsObstructed CBDVenous thrombosis – splenic, portal, mesentericCarcinomaMalabsorbtion
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NEOPLASMTypesExocrine pancreatic tumor – adenocarcinoma, cystic
neoplasmEndocrine pancreatic tumor – insulinoma, gastrinomaOther tumors – lymphoma, metastases
ADENOCARCINOMAClinical – jaundice, weight loss, Courvoisier sign
(enlarged, nontender gallblader)
Radiographic featuresMass effectAlterations of densityExtrapancreatic extensionVascular involvementMetastases
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